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Oronsky B, Larson C, Hammond TC, Oronsky A, Kesari S, Lybeck M, Reid TR. A Review of Persistent Post-COVID Syndrome (PPCS). Clin Rev Allergy Immunol 2023; 64:66-74. [PMID: 33609255 PMCID: PMC7896544 DOI: 10.1007/s12016-021-08848-3] [Citation(s) in RCA: 151] [Impact Index Per Article: 151.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 02/07/2023]
Abstract
Persistent post-COVID syndrome, also referred to as long COVID, is a pathologic entity, which involves persistent physical, medical, and cognitive sequelae following COVID-19, including persistent immunosuppression as well as pulmonary, cardiac, and vascular fibrosis. Pathologic fibrosis of organs and vasculature leads to increased mortality and severely worsened quality of life. Inhibiting transforming growth factor beta (TGF-β), an immuno- and a fibrosis modulator, may attenuate these post-COVID sequelae. Current preclinical and clinical efforts are centered on the mechanisms and manifestations of COVID-19 and its presymptomatic and prodromal periods; by comparison, the postdrome, which occurs in the aftermath of COVID-19, which we refer to as persistent post-COVID-syndrome, has received little attention. Potential long-term effects from post-COVID syndrome will assume increasing importance as a surge of treated patients are discharged from the hospital, placing a burden on healthcare systems, patients' families, and society in general to care for these medically devastated COVID-19 survivors. This review explores underlying mechanisms and possible manifestations of persistent post-COVID syndrome, and presents a framework of strategies for the diagnosis and management of patients with suspected or confirmed persistent post-COVID syndrome.
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Affiliation(s)
- Bryan Oronsky
- EpicentRx Inc, La Jolla, 11099 North Torrey Pines Road, Suite 160, La Jolla, CA 92037 USA
| | - Christopher Larson
- EpicentRx Inc, La Jolla, 11099 North Torrey Pines Road, Suite 160, La Jolla, CA 92037 USA
| | | | | | - Santosh Kesari
- Providence St. John’s Health Center, Santa Monica, CA USA
| | - Michelle Lybeck
- EpicentRx Inc, La Jolla, 11099 North Torrey Pines Road, Suite 160, La Jolla, CA 92037 USA
| | - Tony R. Reid
- EpicentRx Inc, La Jolla, 11099 North Torrey Pines Road, Suite 160, La Jolla, CA 92037 USA
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Acute exacerbation of interstitial lung disease associated with rheumatic disease. Nat Rev Rheumatol 2022; 18:85-96. [PMID: 34876670 DOI: 10.1038/s41584-021-00721-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 11/09/2022]
Abstract
Interstitial lung disease (ILD) is a cause of morbidity and mortality in patients with rheumatic diseases, such as connective-tissue diseases, rheumatoid arthritis and systemic vasculitis. Some patients with ILD secondary to rheumatic disease (RD-ILD) experience acute exacerbations, with sudden ILD progression and high mortality during or immediately after the exacerbation, and a very low 1-year survival rate. In the ILD subtype idiopathic pulmonary fibrosis (IPF), an acute exacerbation is defined as acute worsening or development of dyspnoea associated with new bilateral ground-glass opacities and/or consolidations at high-resolution CT, superimposed on a background pattern consistent with fibrosing ILD. However, acute exacerbation in RD-ILD (AE-RD-ILD) currently has no specific definition. The aetiology and pathogenesis of AE-RD-ILD remain unclear, but distinct triggers might include infection, mechanical stress, microaspiration and DMARD treatment. At this time, no effective evidence-based therapeutic strategies for AE-RD-ILD are available. In clinical practice, AE-RD-ILD is often empirically treated with high-dose systemic steroids and antibiotics, with or without immunosuppressive drugs. In this Review, we summarize the clinical features, diagnosis, management and prognosis of AE-RD-ILD, enabling the similarities and differences with acute exacerbation in IPF to be critically assessed.
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Raciti L, Arcadi FA, Calabrò RS. Could Palmitoylethanolamide Be an Effective Treatment for Long-COVID-19? Hypothesis and Insights in Potential Mechanisms of Action and Clinical Applications. INNOVATIONS IN CLINICAL NEUROSCIENCE 2022; 19:19-25. [PMID: 35382075 PMCID: PMC8970234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
COVID-19 is highly transmissive and contagious disease with a wide spectrum of clinicopathological issues, including respiratory, vasculo-coagulative, and immune disorders. In some cases of COVID-19, patients can be characterized by clinical sequelae with mild-to-moderate symptoms that persist long after the resolution of the acute infection, known as long-COVID, potentially affecting their quality of life. The main symptoms of long-COVID include persistent dyspnea, fatigue and weakness (that are typically out of proportion, to the degree of ongoing lung damage and gas exchange impairment), persistence of anosmia and dysgeusia, neuropsychiatric symptoms, and cognitive dysfunctions (such as brain fog or memory lapses). The appropriate management and prevention of potential long-COVID sequelae is still lacking. It is also believed that long-term symptoms of COVID-19 are related to an immunity over-response, namely a cytokine storm, involving the release of pro-inflammatory interleukins, monocyte chemoattractant proteins, and tissue necrosis factors. Palmitoylethanolamide (PEA) shows affinity for vanilloid receptor 1 and for cannabinoid-like G protein-coupled receptors, enhancing anandamide activity by means of an entourage effect. Due to its anti-inflammatory properties, PEA has been recently used as an early add-on therapy for respiratory problems in patients with COVID-19. It is believed that PEA mitigates the cytokine storm modulating cell-mediated immunity, as well as counteracts pain and oxidative stress. In this article, we theorize that PEA could be a potentially effective nutraceutical to treat long-COVID, with regard to fatigue and myalgia, where a mythocondrial dysfunction is hypothesizable.
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Affiliation(s)
- Loredana Raciti
- Drs. Raciti, Arcadi, and Calabrò are with IRCCS Centro Neurolesi "Bonino Pulejo" in Messina, Italy
| | - Francesca Antonia Arcadi
- Drs. Raciti, Arcadi, and Calabrò are with IRCCS Centro Neurolesi "Bonino Pulejo" in Messina, Italy
| | - Rocco Salvatore Calabrò
- Drs. Raciti, Arcadi, and Calabrò are with IRCCS Centro Neurolesi "Bonino Pulejo" in Messina, Italy
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Polke M, Kahn N, Kreuter M. [Exacerbation in Idiopathic Pulmonary Fibrosis]. Pneumologie 2021; 75:601-610. [PMID: 34374062 DOI: 10.1055/a-1273-4105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Acute exacerbations (AE) are a life-threatening complication in patients with idiopathic pulmonary fibrosis (IPF). In-hospital mortality is high and the overall prognosis poor. The underlying causes of AE-IPF still remain unclear and there are no focused guidelines for its management. In most cases high-dose steroids combined with an antibiotic therapy are applied. Preventive and palliative measures are very important. Intensive research is necessary to improve management of AE-IPF.
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Rodavsky G, Sheiner E, Walfisch A, Gutvirtz G, Hermon N, Landau D, Wainstock T. Meconium stained amniotic fluid exposure and long-term respiratory morbidity in the offspring. Pediatr Pulmonol 2021; 56:2328-2334. [PMID: 33730429 DOI: 10.1002/ppul.25357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/07/2021] [Accepted: 02/16/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Meconium stained amniotic fluid (MSAF) is a well-established risk factor for neonatal short-term respiratory complications. Little is known regarding the long-term morbidity. We investigated the possible association between MSAF and offspring respiratory morbidity. METHODS A population-based, cohort study of singleton deliveries occurring between 1991 and 2014 at a sole regional tertiary medical center was performed. Incidence of offspring respiratory related hospitalizations up to the age of 18 years were evaluated and compared to unexposed offspring. A Kaplan-Meier survival curve was used to compare cumulative respiratory morbidity incidence, and a Cox proportional hazards model was used to control for confounders. RESULTS During the study period 242,342 deliveries met the inclusion criteria. Of them, 14.7% (n = 35,609) were complicated with MSAF. Incidence of respiratory-related hospitalizations was significantly lower in children exposed to MSAF as compared to the unexposed group (4.5% vs. 4.9%, respectively; p < .01). Specifically, hospitalizations involving pneumonitis were significantly less common among the MSAF group (odds ratio, 0.35; 95% confidence interval [95% CI], 0.13-0.96; p = .03). The Kaplan-Meier survival curve demonstrated significantly lower total cumulative respiratory morbidity rates in the MSAF exposed group (log rank p < .01). In the Cox model, controlled for clinically relevant confounders, MSAF exhibited an independent and significant protective effect on long-term childhood respiratory morbidity (aHR, 0.91; 95% CI, 0.86-0.96; p < .01). CONCLUSIONS Fetal exposure to MSAF during labor appears to be associated with lower rates of long-term respiratory related hospitalizations in the offspring. Changes in offspring microbiome, as well as functional and anatomical modulations possibly resulting from MSAF exposure, might offer a plausible explanation of our findings.
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Affiliation(s)
- Gal Rodavsky
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Asnat Walfisch
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Gil Gutvirtz
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Narkis Hermon
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Daniella Landau
- Department of Neonatology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Tamar Wainstock
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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McDowell BJ, Karamchandani K, Lehman EB, Conboy MJ, Carr ZJ. Perioperative risk factors in patients with idiopathic pulmonary fibrosis: a historical cohort study. Can J Anaesth 2020; 68:81-91. [PMID: 33029686 DOI: 10.1007/s12630-020-01828-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 07/26/2020] [Accepted: 08/10/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Perioperative complications of patients with idiopathic pulmonary fibrosis (IPF) are not well described. The aim of this study was to identify risk factors associated with adverse postoperative outcomes in IPF patients. METHODS We performed a single-centre historical cohort study of adult patients with IPF who underwent surgery between 2008 and 2018. We analyzed the prognostic utility of select perioperative factors for postoperative acute exacerbation of IPF (AE-IPF), acute respiratory worsening (ARW), pneumonia, and 30-day and one-year mortality using univariable and multivariable regression analyses. To adjust for multiple interactions, the false discovery rate (Q value) was utilized to appropriately adjust P values and a Q value < 0.05 was considered to be significant. RESULTS Two hundred and eighty-two patients were identified. After excluding emergency cases and bronchoscopies performed for active pneumonia, 14.2% of the cohort developed ARW that persisted > 24 hr after surgery, 5.0% had AE-IPF, and 9.2% were diagnosed with postoperative pneumonia within 30 days of surgery. The 30-day mortality was 6.0% and the one-year mortality was 14.9%. Preoperative home oxygen use (relative risk [RR], 2.70; 95% confidence interval [CI], 1.50 to 4.86; P < 0.001) and increasing surgical time (per 60 min) (RR, 1.03; 95% CI, 1.02 to 1.05; P < 0.001) were identified as independent risk factors for postoperative ARW. CONCLUSIONS In IPF patients, preoperative home oxygen requirement and increasing surgical time showed a strong relationship with postoperative ARW and may be useful markers for perioperative risk stratification. Facteurs de risque périopératoires des patients atteints de fibrose pulmonaire idiopathique : une étude de cohorte historique.
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Affiliation(s)
- Brittany J McDowell
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Penn State University College of Medicine, Hershey, PA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Penn State University College of Medicine, Hershey, PA, USA
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State University College of Medicine, Hershey, PA, USA
| | | | - Zyad J Carr
- Department of Anesthesiology, Yale New Haven Hospital, 20 York St., New Haven, CT, 06510, USA.
- Yale School of Medicine, New Haven, CT, USA.
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Rinciog C, Diamantopoulos A, Gentilini A, Bondue B, Dahlqvist C, Froidure A, Wuyts WA, Soulard S. Cost-Effectiveness Analysis of Nintedanib Versus Pirfenidone in Idiopathic Pulmonary Fibrosis in Belgium. PHARMACOECONOMICS - OPEN 2020; 4:449-458. [PMID: 31939146 PMCID: PMC7426351 DOI: 10.1007/s41669-019-00191-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Nintedanib (Ofev®) and pirfenidone (Esbriet®) are recommended by international guidelines as treatment options for idiopathic pulmonary fibrosis (IPF). OBJECTIVES To compare the cost-effectiveness of nintedanib with that of pirfenidone for the treatment of IPF from a Belgian healthcare payer perspective. METHODS The economic analysis used a Markov model that calculated outcomes over patient lifetime. Overall survival was assumed to be the same for the two comparators. Data from a network meta-analysis were used for loss of lung function, acute exacerbation events, safety and treatment discontinuation (for any reason). The health-state utility estimates in the model were calculated from EQ-5D scores collected in nintedanib studies. The assumed resource use for background care was also based on patient-level data that were categorised to fit the health states in the model and synthesised with costs and tariffs from Belgian national databases. RESULTS Treatment with nintedanib resulted in an estimated total cost of €102,315, which was less than the total cost of treatment with pirfenidone (€113,313). Given the similarities in the survival and progression outcomes obtained with nintedanib and pirfenidone, the model predicted near equivalence in total QALYs (3.353 QALYs for the nintedanib arm and 3.318 for the pirfenidone arm). Results were largely driven by model assumptions underlying mortality, acute exacerbations and treatment discontinuation. CONCLUSIONS After performing a synthesis of the most recently published evidence for IPF patients and assuming a Belgian healthcare payer perspective, we found nintedanib to be more cost-saving than pirfenidone.
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Affiliation(s)
- C Rinciog
- Symmetron Limited, 8 Devonshire Square, London, UK.
| | | | - A Gentilini
- Symmetron Limited, 8 Devonshire Square, London, UK
| | - B Bondue
- Department of Respiratory Medicine, Erasme University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - C Dahlqvist
- Department of Pneumology, CHU UCL Namur Site Godinne, Yvoir, Belgium
| | - A Froidure
- Department of Pneumology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - W A Wuyts
- Unit for Interstitial Lung Diseases, Department of Respiratory Medicine, University Hospitals Leuven, Louvain, Belgium
| | - S Soulard
- Boehringer Ingelheim, Amsterdam, The Netherlands
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Yamamoto N, Anzai A, Okamura K, Gamo M, Goto T. Risk factors for prolonged postoperative oxygen supplementation dependence after surgical lung biopsy in patients with interstitial pneumonia: A single-center, retrospective, observational study. J Clin Anesth 2020; 65:109878. [PMID: 32464478 DOI: 10.1016/j.jclinane.2020.109878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/16/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Natsuhiro Yamamoto
- Department of Anesthesiology, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka higashi, Kanazawa-ku, Yokohama, Kanagawa 236-0051, Japan.
| | - Akiko Anzai
- Department of Anesthesiology, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka higashi, Kanazawa-ku, Yokohama, Kanagawa 236-0051, Japan
| | - Kenta Okamura
- Department of Anesthesiology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
| | - Masahiro Gamo
- Department of Anesthesiology, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka higashi, Kanazawa-ku, Yokohama, Kanagawa 236-0051, Japan
| | - Takahisa Goto
- Department of Anesthesiology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
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Prognostic Value of Serum Osteopontin in Acute Exacerbation of Idiopathic Pulmonary Fibrosis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3424208. [PMID: 32104688 PMCID: PMC7035537 DOI: 10.1155/2020/3424208] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 10/30/2019] [Accepted: 11/19/2019] [Indexed: 12/14/2022]
Abstract
Background Acute exacerbation (AE) is a common cause of rapid deterioration and high mortality in idiopathic pulmonary fibrosis (IPF) patients. Osteopontin (OPN) plays an important role in IPF, but the studies about serum OPN in AE-IPF are unclear. We aimed to investigate whether OPN had a potential prognostic value in acute exacerbation and mortality in IPF. Methods Thirty-two patients with AE-IPF, 39 with S-IPF, and 20 healthy controls were included. Serum OPN and KL-6 levels were compared between AE-IPF and S-IPF. Logistic regression analysis was applied to identify the predicted value of OPN for AE. Kaplan-Meier curves were used to display survival, and Cox proportional hazards regression was used to identify risk for mortality. Results In AE-IPF patients, serum OPN levels were significantly higher than in S-IPF subjects (p < 0.001) or healthy controls (p < 0.001) or healthy controls (p < 0.001) or healthy controls (p < 0.001) or healthy controls (p < 0.001) or healthy controls (p < 0.001) or healthy controls (p < 0.001) or healthy controls (p < 0.001) or healthy controls (p < 0.001) or healthy controls (p < 0.001) or healthy controls (. Conclusion Elevated OPN could be a potential serum predictor for AE status and survival in IPF patients.
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The Role of Infection in Acute Exacerbation of Idiopathic Pulmonary Fibrosis. Mediators Inflamm 2019; 2019:5160694. [PMID: 30718973 PMCID: PMC6335849 DOI: 10.1155/2019/5160694] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/03/2018] [Accepted: 11/05/2018] [Indexed: 11/18/2022] Open
Abstract
Background Acute exacerbation of IPF (AE-IPF) is associated with high mortality. We studied changes in pathogen involvement during AE-IPF and explored a possible role of infection in AE-IPF. Objectives Our purpose is to investigate the role of infection in AE-IPF. Methods Overall, we recruited 170 IPF patients (48 AE-IPF, 122 stable) and 70 controls at Shanghai Pulmonary Hospital. Specific IgM against microbial pathogens and pathogens in sputum were assessed. RNA sequences of pathogens in nasopharyngeal swab of IPF patients were detected by PathChip. A panel of serum parameters reflecting immune function were assessed. Results Antiviral/bacterial IgM was higher in IPF vs. controls and in AE-IPF vs. stable IPF. Thirty-eight different bacterial strains were detected in IPF patient sputum. Bacteria-positive results were found in 9/48 (18.8%) of AE-IPF and in 26/122 (21.3%) stable IPF. Fifty-seven different viruses were detected in nasopharyngeal swabs of IPF patients. Virus-positive nasopharyngeal swabs were found in 18/30 (60%) of tested AE-IPF and in 13/30 (43.3%) of stable IPF. AE-IPF showed increased inflammatory cytokines (IL-6, IFN-γ, MIG, IL-17, and IL-9) vs. stable IPF and controls. Mortality of AE-IPF in one year (39.5%) was higher compared to stable IPF (28.7%).Conclusions. IPF patients had different colonization with pathogens in sputum and nasopharyngeal swabs; they also displayed abnormally activated immune response, which was exacerbated during AE-IPF.
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Kolb M, Bondue B, Pesci A, Miyazaki Y, Song JW, Bhatt NY, Huggins JT, Oldham JM, Padilla ML, Roman J, Shapera S. Acute exacerbations of progressive-fibrosing interstitial lung diseases. Eur Respir Rev 2018; 27:27/150/180071. [DOI: 10.1183/16000617.0071-2018] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/08/2018] [Indexed: 12/21/2022] Open
Abstract
Acute exacerbation of interstitial lung disease (ILD) is associated with a poor prognosis and high mortality. Numerous studies have documented acute exacerbation in idiopathic pulmonary fibrosis (IPF), but less is known about these events in other ILDs that may present a progressive-fibrosing phenotype. We propose defining acute exacerbation as an acute, clinically significant respiratory deterioration, typically less than 1 month in duration, together with computerised tomography imaging showing new bilateral glass opacity and/or consolidation superimposed on a background pattern consistent with fibrosing ILDs. Drawing on observations in IPF, it is suspected that epithelial injury or proliferation and autoimmunity are risk factors for acute exacerbation in ILDs that may present a progressive-fibrosing phenotype, but further studies are required. Current acute exacerbation management strategies are based on recommendations in IPF, but no randomised controlled trials of acute exacerbation management have been performed. Although there are no formal strategies to prevent the development of acute exacerbation, possible approaches include antifibrotic drugs (such as nintedanib and pirfenidone), and minimising exposure to infection, airborne irritants and pollutants. This review discusses the current knowledge of acute exacerbation of ILDs that may present a progressive-fibrosing phenotype and acknowledges limitations of the data available.
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Chen T, Qiu H, Zhao MM, Chen SS, Wu Q, Zhou NY, Lu LQ, Song JC, Tang DL, Weng D, Li HP. IL-17A contributes to HSV1 infection-induced acute lung injury in a mouse model of pulmonary fibrosis. J Cell Mol Med 2018; 23:908-919. [PMID: 30378252 PMCID: PMC6349191 DOI: 10.1111/jcmm.13992] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 09/09/2018] [Accepted: 10/07/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patients with idiopathic pulmonary fibrosis (IPF) often experience acute exacerbation (AE) after an episode of common cold. AIMS To establish a mouse model of virus infection-induced AE-IPF and investigate the mechanism underlying the AE-IPF. METHODS Herpes simplex virus 1 (HSV1) was inoculated intranasally to wild-type (WT) and IL-17A gene knockout (IL-17A-/- ) mice 21 days after intratracheal administration of bleomycin (BLM). RESULTS HSV1 infection caused acute exacerbation in mice with BLM-induced fibrosis. Compared with the BLM+Saline mice, the mice with BLM+HSV1 showed significantly higher acute lung injury (ALI) score (P < 0.0001), lower survival rate (100% vs 21.4%, P < 0.0001), poorer lung function and higher inflammatory response representing by increased total inflammatory cells in bronchoalveolar lavage fluid (BALF) (P = 0.0323), increased proportion of Th17 cells in peripheral blood (P = 0.0004) and higher inflammatory factors in BALF. In addition, HSV1 infection increased the expression of endoplasmic reticulum stress (ERS)-related proteins in mice with BLM-induced fibrosis. The inhibition of ERS by tauroursodeoxycholic acid (TUDCA, an ERS inhibitor) significantly reduced the IL-17A levels in BALF (P = 0.0140) and TH17 cells in the peripheral blood (P = 0.0084) of mice with BLM+HSV1, suggesting that suppression of ERS may reduce TH17 response in mice with AE-IPF. Compared with WT mice with BLM+HSV1, IL-17A-/- mice with BLM+HSV1 had lower ALI score (P = 0.0119), higher survival rate (78.6% vs 21.4%, P = 0.004), improved lung function, and milder inflammatory response. CONCLUSIONS HSV1 infection in addition to BLM-induced IPF can successfully establish AE-IPF in mice. IL-17A and ERS promote lung inflammation in AE-IPF development.
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Affiliation(s)
- Tao Chen
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Hui Qiu
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Meng-Meng Zhao
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Shan-Shan Chen
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Soochow University, Suzhou, China
| | - Qin Wu
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Nian-Yu Zhou
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Li-Qin Lu
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Jia-Cui Song
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Soochow University, Suzhou, China
| | - Dan-Li Tang
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Dong Weng
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Hui-Ping Li
- Department of Respiratory Medicine, School of Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
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Nafe LA, Grobman ME, Masseau I, Reinero CR. Aspiration-related respiratory disorders in dogs. J Am Vet Med Assoc 2018; 253:292-300. [DOI: 10.2460/javma.253.3.292] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kondoh Y, Cottin V, Brown KK. Recent lessons learned in the management of acute exacerbation of idiopathic pulmonary fibrosis. Eur Respir Rev 2017; 26:26/145/170050. [PMID: 28954766 PMCID: PMC9488992 DOI: 10.1183/16000617.0050-2017] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/04/2017] [Indexed: 12/24/2022] Open
Abstract
Recognising recent advances, the definition and diagnostic criteria for acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) have been updated by an international working group. The new definition describes any acute, clinically significant respiratory deterioration (both idiopathic and triggered events) characterised by evidence of new widespread alveolar abnormality. The new criteria require a previous or concurrent diagnosis of IPF, an acute worsening or development of dyspnoea typically less than 1 month in duration, chest imaging evidence on computed tomography (CT) of new bilateral ground-glass opacity and/or consolidation superimposed on a background imaging pattern of usual interstitial pneumonia not fully explained by cardiac failure or fluid overload. Due to high in-hospital mortality rates, current treatment guidelines say that the majority of patients with AE-IPF should not receive mechanical ventilation. However, new data suggest that the prognosis may have improved. This modest improvement in overall survival seen in more recent studies may be the result of differences in the diagnostic criteria, study design, baseline clinical risk factors and/or improvements in management. Based on our updated knowledge of possible preventive and therapeutic measures, including mechanical ventilation and pharmacological therapies, the current approach to the treatment of AE-IPF requires careful decision-making. Recent preventive and therapeutic measures for acute exacerbation of IPF may modestly improve short-term survivalhttp://ow.ly/n6GK30e8mN5
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Affiliation(s)
- Yasuhiro Kondoh
- Dept of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Dept of Respiratory Medicine, Louis Pradel Hospital, Claude Bernard University Lyon 1, Lyon, France
| | - Kevin K Brown
- Dept of Medicine, National Jewish Health, Denver, CO, USA
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Maher TM, Molina-Molina M, Russell AM, Bonella F, Jouneau S, Ripamonti E, Axmann J, Vancheri C. Unmet needs in the treatment of idiopathic pulmonary fibrosis-insights from patient chart review in five European countries. BMC Pulm Med 2017; 17:124. [PMID: 28915874 PMCID: PMC5602932 DOI: 10.1186/s12890-017-0468-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 08/31/2017] [Indexed: 11/18/2022] Open
Abstract
Background Two antifibrotic drugs, pirfenidone and nintedanib, are approved by the European Medicines Agency and the US Food and Drug Administration for the treatment of idiopathic pulmonary fibrosis (IPF). In this analysis, treatment patterns of European patients with IPF were investigated to understand antifibrotic prescribing and identify unmet needs in IPF treatment practice. Methods Between February and March 2016, respiratory physicians from France, Germany, Italy, Spain, and the UK participated in an online questionnaire designed to collect information on IPF treatment patterns in patients under their care. Patients were categorized as treated (received approved antifibrotics) or untreated (did not receive approved antifibrotics, but may have received other unapproved therapies). Classification of IPF diagnosis (confirmed/suspected) and severity (‘mild’/‘moderate’/‘severe’) for each patient was based on the individual physician’s report. Patients’ perspectives were not recorded in this study. Results In total, 290 physicians responded to the questionnaire. Overall, 54% of patients with IPF did not receive treatment with an approved antifibrotic. More patients had a confirmed IPF diagnosis in the treated (84%) versus the untreated (51%) population. Of patients with a confirmed diagnosis, 40% did not receive treatment. The treated population was younger than the untreated population (67 vs 70 years, respectively; p ≤ 0.01), with more frequent multidisciplinary team evaluation (83% vs 57%, respectively; p ≤ 0.01). A higher proportion of untreated patients had forced vital capacity > 80% at diagnosis versus treated patients. Of patients with ‘mild’ IPF, 71% did not receive an approved antifibrotic versus 41% and 60% of patients with ‘moderate’ and ‘severe’ IPF, respectively. Conclusions Despite the availability of antifibrotic therapies, many European patients with confirmed IPF do not receive approved antifibrotic treatment. Importantly, there appears to be a reluctance to treat patients with ‘mild’ or ‘stable’ disease, and instead adopt a ‘watch and wait’ approach. More education is required to address diagnostic uncertainty, poor understanding of IPF and its treatments, and issues of treatment access. There is a need to increase physician awareness of the benefits associated with antifibrotic treatment across the spectrum of IPF severity. Electronic supplementary material The online version of this article (10.1186/s12890-017-0468-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Toby M Maher
- NIHR Respiratory Biomedical Research Unit, Royal Brompton Hospital and Fibrosis Research Group, National Heart and Lung Institute, Imperial College London, London, UK. .,Fibrosis Research Group, Inflammation, Repair and Development Section, NHLI, Sir Alexander Fleming Building, Imperial College London, London, SW7 2AZ, UK.
| | - Maria Molina-Molina
- University Hospital of Bellvitge, Institut d'Investigacions Biomèdiques de Bellvitge (IDIBELL), Barcelona, and Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Anne-Marie Russell
- NIHR Respiratory Biomedical Research Unit, Royal Brompton Hospital and Fibrosis Research Group, National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Stéphane Jouneau
- Hôpital Pontchaillou, IRSET UMR 1085, Université de Rennes 1, Rennes, France
| | | | | | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases, University of Catania, Catania, Italy
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Kishaba T, Nagano H, Nei Y, Yamashiro S. Body mass index-percent forced vital capacity-respiratory hospitalization: new staging for idiopathic pulmonary fibrosis patients. J Thorac Dis 2016; 8:3596-3604. [PMID: 28149554 DOI: 10.21037/jtd.2016.12.49] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is relentless progressive interstitial lung disease. Evaluating predictor of mortality for IPF patients is crucial. The aim of this study was to evaluate the serial trend of important indicators of prognosis and create a useful staging method for IPF patients. METHODS We retrospectively searched medical records, pulmonary function tests (PFTs), and chest high resolution computed tomography (HRCT) scans from January 1, 2008 through June 30, 2015 at our hospital. We also evaluated the same parameters 1-year later. RESULTS We identified 65 IPF patients. The mean age was 71.9±1.8 years (range, 22-85 years). In terms of PFTs, mean percent predicted forced vital capacity (%FVC) was 69.8±2.7. Baseline mean body mass index (BMI) was 24.3±0.6 kg/mm2. Mean survival was 39.2 months (range, 0.9-158.9 months). Cox proportional hazard ratios (HRs) showed the following to be predictors of mortality in IPF patients: 1-year BMI (HR: 0.899; 95% CI: 0.825-0.979; P=0.021); 1-year %FVC (HR: 0.932; 95% CI: 0.887-0.979; P=0.005) and 1-year respiratory hospitalization (HR: 3.307; 95% CI: 2.149-5.090; P<0.001). On the basis of these date, we created a new staging method for predicting mortality for IPF patients, consisting of delta BMI, delta %FVC and respiratory hospitalization within a year following diagnosis of IPF (BFR staging). We stratified patients into one of three groups according to the composite points. Mean survival of stages 1, 2, and 3 was 77.9 (30.8-158.9), 43.9 (0.9-145.2) and 14.8 (3.5-32) months (P<0.001), respectively. CONCLUSIONS In our cohort of IPF patients, this new staging method, including delta BMI and delta %FVC and respiratory hospitalization within 1-year showed a clear survival difference.
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Affiliation(s)
- Tomoo Kishaba
- Department of Respiratory Medicine, Okinawa Chubu Hospital, Uruma City, Japan
| | - Hiroaki Nagano
- Department of Respiratory Medicine, Okinawa Chubu Hospital, Uruma City, Japan
| | - Yuichiro Nei
- Department of Respiratory Medicine, Okinawa Chubu Hospital, Uruma City, Japan
| | - Shin Yamashiro
- Department of Respiratory Medicine, Okinawa Chubu Hospital, Uruma City, Japan
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Clement A, de Blic J, Epaud R, Galeron L, Nathan N, Hadchouel A, Barbato A, Snijders D, Kiper N, Cunningham S, Griese M, Bush A, Schwerk N. Management of children with interstitial lung diseases: the difficult issue of acute exacerbations. Eur Respir J 2016; 48:1559-1563. [DOI: 10.1183/13993003.01900-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/16/2016] [Indexed: 11/05/2022]
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18
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Murray LA, Grainge C, Wark PA, Knight DA. Use of biologics to treat acute exacerbations and manage disease in asthma, COPD and IPF. Pharmacol Ther 2016; 169:1-12. [PMID: 27889330 DOI: 10.1016/j.pharmthera.2016.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A common feature of chronic respiratory disease is the progressive decline in lung function. The decline can be indolent, or it can be accelerated by acute exacerbations, whereby the patient experiences a pronounced worsening of disease symptoms. Moreover, acute exacerbations may also be a marker of insufficient disease management. The underlying cause of an acute exacerbation can be due to insults such as pathogens or environmental pollutants, or the cause can be unknown. For each acute exacerbation, the patient may require medical intervention such as rescue medication, or in more severe cases, hospitalization and ventilation and have an increased risk of death. Biologics, such as monoclonal antibodies, are being developed for chronic respiratory diseases including asthma, COPD and IPF. This therapeutic approach is particularly well suited for chronic use based on the route and frequency of delivery and importantly, the potential for disease modification. In recent clinical trials, the frequency of acute exacerbation has often been included as an endpoint, to help determine whether the investigational agent is impacting disease. Therefore the significance of acute exacerbations in driving disease, and their potential as a marker of disease activity and progression, has recently received much attention. There is also now a need to standardize the definition of an acute exacerbation in specific disease settings, particularly as this endpoint is increasingly used in clinical trials to also assess therapeutic efficacy. Moreover, specifically targeting exacerbations may offer a new therapeutic approach for several chronic respiratory diseases.
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Affiliation(s)
| | - Chris Grainge
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia
| | - Peter A Wark
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia
| | - Darryl A Knight
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, Australia; School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
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Nakamura Y, Suda T. Idiopathic Pulmonary Fibrosis: Diagnosis and Clinical Manifestations. Clin Med Insights Circ Respir Pulm Med 2016; 9:163-71. [PMID: 27625576 PMCID: PMC5013866 DOI: 10.4137/ccrpm.s39897] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/03/2016] [Accepted: 07/05/2016] [Indexed: 12/16/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a parenchymal lung disease characterized by progressive interstitial fibrosis. The clinical course of IPF can be unpredictable and may be punctuated by acute exacerbations. Although much progress is being made in unraveling the mechanisms underlying IPF, effective therapy for improving survival remains elusive. Longitudinal disease profiling, especially in terms of clinical manifestations in a large cohort of patients, should lead to proper management of the patients and development of new treatments for IPF. Appropriate multidisciplinary assessment in ongoing registries is required to achieve this. This review summarizes the current status of the diagnosis and clinical manifestations of IPF.
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Affiliation(s)
- Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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20
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Plasma Leptin Is Elevated in Acute Exacerbation of Idiopathic Pulmonary Fibrosis. Mediators Inflamm 2016; 2016:6940480. [PMID: 27642238 PMCID: PMC5014970 DOI: 10.1155/2016/6940480] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 05/12/2016] [Accepted: 06/16/2016] [Indexed: 01/29/2023] Open
Abstract
Background. The natural history of idiopathic pulmonary fibrosis (IPF) is very complex and unpredictable. Some patients will experience acute exacerbation (AE) and fatal outcomes. Methods. The study included 30 AE-IPF patients, 32 stable IPF (S-IPF) patients, and 12 healthy controls. We measured the plasma concentrations of leptin and KL-6. Simple correlation was used to assess associations between leptin and other variables. Plasma leptin levels were compared between AE-IPF and S-IPF subjects, decedents, and survivors. Kaplan-Meier curves were used to display survival and Cox proportional hazards regression was used to examine risk factors for survival. Results. In subjects with AE-IPF, plasma leptin was significantly greater than in subjects with S-IPF (p = 0.0003) or healthy controls (p < 0.0001). Plasma leptin was correlated with BMI, KL-6, LDH, CRP, and PaO2/FiO2 (p = 0.007; p = 0.005; p = 0.003; p = 0.033; and p = 0.032, resp.). Plasma leptin was significantly greater in 33 decedents than in the 23 survivors (p = 0.007). Multivariate Cox regression analysis showed leptin (>13.79 ng/mL) was an independent predictor of survival (p = 0.004). Conclusions. Leptin could be a promising plasma biomarker of AE-IPF occurrence and predictor of survival in IPF patients.
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21
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Prasad J, Holland AE, Glaspole I, Westall G. Idiopathic pulmonary fibrosis: an Australian perspective. Intern Med J 2016; 46:663-8. [DOI: 10.1111/imj.13078] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 12/13/2015] [Accepted: 12/13/2015] [Indexed: 01/20/2023]
Affiliation(s)
- J. Prasad
- Allergy Immunology and Respiratory Medicine; Alfred Hospital; Melbourne Victoria Australia
- Clinical School of Medicine; Monash University; Melbourne Victoria Australia
| | - A. E. Holland
- Allergy Immunology and Respiratory Medicine; Alfred Hospital; Melbourne Victoria Australia
- Department of Physiotherapy; La Trobe University; Melbourne Victoria Australia
| | - I. Glaspole
- Allergy Immunology and Respiratory Medicine; Alfred Hospital; Melbourne Victoria Australia
| | - G. Westall
- Allergy Immunology and Respiratory Medicine; Alfred Hospital; Melbourne Victoria Australia
- Clinical School of Medicine; Monash University; Melbourne Victoria Australia
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22
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Taniguchi H, Kondoh Y. Acute and subacute idiopathic interstitial pneumonias. Respirology 2016; 21:810-20. [PMID: 27123874 DOI: 10.1111/resp.12786] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/07/2016] [Accepted: 02/09/2016] [Indexed: 12/12/2022]
Abstract
Idiopathic interstitial pneumonias (IIPs) may have an acute or subacute presentation, or acute exacerbation may occur in a previously subclinical or unrecognized chronic IIP. Acute or subacute IIPs include acute interstitial pneumonia (AIP), cryptogenic organizing pneumonia (COP), nonspecific interstitial pneumonia (NSIP), acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) and AE-NSIP. Interstitial lung diseases (ILDs) including connective tissue disease (CTD) associated ILD, hypersensitivity pneumonitis, acute eosinophilic pneumonia, drug-induced lung disease and diffuse alveolar haemorrhage need to be differentiated from acute and subacute IIPs. Despite the severe lack of randomized controlled trials for the treatment of acute and subacute IIPs, the mainstream treatment remains corticosteroid therapy. Other potential therapies reported in the literature include corticosteroids and immunosuppression, antibiotics, anticoagulants, neutrophil elastase inhibitor, autoantibody-targeted treatment, antifibrotics and hemoperfusion therapy. With regard to mechanical ventilation, patients in recent studies with acute and subacute IIPs have shown better survival than those in previous studies. Therefore, a careful value-laden decision about the indications for endotracheal intubation should be made for each patient. Noninvasive ventilation may be beneficial to reduce ventilator associated pneumonia.
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Affiliation(s)
- Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
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Abstract
The lung is a common site of complications of systemic connective tissue disease (CTD), and lung involvement can present in several ways. Interstitial lung disease (ILD) and pulmonary hypertension are the most common lung manifestations in CTD. Although it is generally thought that interstitial lung disease develops later on in CTD it is often the initial presentation ("lung dominant" CTD). ILD can be present in most types of CTD, including rheumatoid arthritis, scleroderma, systemic lupus erythematosus, polymyositis or dermatomyositis, Sjögren's syndrome, and mixed connective tissue disease. Despite similarities in clinical and pathologic presentation, the prognosis and treatment of CTD associated ILD (CTD-ILD) can differ greatly from that of other forms of ILD, such as idiopathic pulmonary fibrosis. Pulmonary hypertension (PH) can present as a primary vasculopathy in pulmonary arterial hypertension or in association with ILD (PH-ILD). Therefore, detailed history, physical examination, targeted serologic testing, and, occasionally, lung biopsy are needed to diagnose CTD-ILD, whereas both non-invasive and invasive assessments of pulmonary hemodynamics are needed to diagnose pulmonary hypertension. Immunosuppression is the mainstay of treatment for ILD, although data from randomized controlled trials (RCTs) to support specific treatments are lacking. Furthermore, treatment strategies vary according to the clinical situation-for example, the treatment of a patient newly diagnosed as having CTD-ILD differs from that of someone with an acute exacerbation of the disease. Immunosuppression is indicated only in select cases of pulmonary arterial hypertension related to CTD; more commonly, selective pulmonary vasodilators are used. For both diseases, comorbidities such as sleep disordered breathing, symptoms of dyspnea, and cough should be evaluated and treated. Lung transplantation should be considered in patients with advanced disease but is not always feasible because of other manifestations of CTD and comorbidities. Clinical trials of novel therapies including immunosuppressive therapies are needed to inform best treatment strategies.
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Affiliation(s)
- Stephen C Mathai
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sonye K Danoff
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Papiris SA, Kagouridis K, Kolilekas L, Papaioannou AI, Roussou A, Triantafillidou C, Baou K, Malagari K, Argentos S, Kotanidou A, Karakatsani A, Manali ED. Survival in Idiopathic pulmonary fibrosis acute exacerbations: the non-steroid approach. BMC Pulm Med 2015; 15:162. [PMID: 26666385 PMCID: PMC4678631 DOI: 10.1186/s12890-015-0146-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 11/18/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis acute exacerbation (IPF-AE) constitutes IPF's most devastating event, representing the unexpected superimposition of diffuse alveolar damage of unknown etiology. Guidelines recommend high-dose steroids treatment despite unproven benefit. We hypothesized that previous immunosuppression and the administration of high-dose steroids adversely affect IPF-AE outcome. METHODS We studied all consecutive patients hospitalized in our department for IPF deterioration from 2007 to June 2013. Our protocol consisted of immediate cessation of immunosuppression (if any), best supportive care, broad-spectrum antimicrobials and thorough evaluation to detect reversible causes of deterioration. Patients were followed-up for survival; post-discharge none received immunosuppression. RESULTS Twenty-four out of 85 admissions (28%) fulfilled IPF-AE criteria. IPF-AE were analyzed both as unique events and as unique patients. As unique events 50% survived; 3 out of 12 (25%) in the group previously treated with immunosuppression whereas nine out of 12 (75%) in the group not receiving immunosuppression (p = 0.041). As unique patients 35.3% survived; 3 out of 6 (50%) in the never treated group whereas three out of 11 (27.3%) in the group receiving immunosuppression (p = 0.685). The history of immunosuppression significantly and adversely influenced survival (p = 0.035). Survival was greater in the never treated group compared to the immunosuppressed patients (p = 0.022). Post-discharge, our IPF-AE survivors had an 83% 1-year survival. CONCLUSIONS By applying the above mentioned protocol half of our patients survived. The history of immunosuppression before IPF-AE adversely influences survival. Avoiding steroids in IPF patients may favor the natural history of the disease even at the moment of its most devastating event.
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Affiliation(s)
- Spyros A Papiris
- 2nd Pulmonary Medicine Department, Attikon University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Konstantinos Kagouridis
- 2nd Pulmonary Medicine Department, Attikon University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Likurgos Kolilekas
- 7th Pulmonary Department and Asthma Center, Sotiria Chest Diseases Hospital, Athens, Greece.
| | - Andriana I Papaioannou
- 2nd Pulmonary Medicine Department, Attikon University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Aneza Roussou
- 2nd Pulmonary Medicine Department, Attikon University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | | | - Katerina Baou
- 4th Pulmonary Department, Sotiria Chest Diseases Hospital, Athens, Greece.
| | - Katerina Malagari
- Imaging and Research Unit, Evgenidion University Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Stylianos Argentos
- 2nd Pulmonary Medicine Department, Attikon University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Anastasia Kotanidou
- 1st Department of Critical Care, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Anna Karakatsani
- 2nd Pulmonary Medicine Department, Attikon University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Effrosyni D Manali
- 2nd Pulmonary Medicine Department, Attikon University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
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Sgalla G, Biffi A, Richeldi L. Idiopathic pulmonary fibrosis: Diagnosis, epidemiology and natural history. Respirology 2015; 21:427-37. [DOI: 10.1111/resp.12683] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/10/2015] [Accepted: 10/05/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Giacomo Sgalla
- National Institute for Health Research, Southampton Respiratory Biomedical Research Unit; Southampton University Hospital; Southampton UK
| | - Alice Biffi
- National Institute for Health Research, Southampton Respiratory Biomedical Research Unit; Southampton University Hospital; Southampton UK
- Clinic of Respiratory Medicine, Department of Health Science; University Hospital ‘San Gerardo’; Monza Italy
| | - Luca Richeldi
- National Institute for Health Research, Southampton Respiratory Biomedical Research Unit; Southampton University Hospital; Southampton UK
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Disayabutr S, Calfee CS, Collard HR, Wolters PJ. Interstitial lung diseases in the hospitalized patient. BMC Med 2015; 13:245. [PMID: 26407727 PMCID: PMC4584017 DOI: 10.1186/s12916-015-0487-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 09/11/2015] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Interstitial lung diseases (ILDs) are disorders of the lung parenchyma. The pathogenesis, clinical manifestations, and prognosis of ILDs vary depending on the underlying disease. The onset of most ILDs is insidious, but they may also present subacutely or require hospitalization for management. ILDs that may present subacutely include acute interstitial pneumonia, connective tissue disease-associated ILDs, cryptogenic organizing pneumonia, acute eosinophilic pneumonia, drug-induced ILDs, and acute exacerbation of idiopathic pulmonary fibrosis. Prognosis and response to therapy depend on the type of underlying ILD being managed. DISCUSSION This opinion piece discusses approaches to differentiating ILDs in the hospitalized patient, emphasizing the role of bronchoscopy and surgical lung biopsy. We then consider pharmacologic treatments and the use of mechanical ventilation in hospitalized patients with ILD. Finally, lung transplantation and palliative care as treatment modalities are considered. The diagnosis of ILD in hospitalized patients requires input from multiple disciplines. The prognosis of ILDs presenting acutely vary depending on the underlying ILD. Patients with advanced ILD or acute exacerbation of idiopathic pulmonary fibrosis have poor outcomes. The mainstay treatment in these patients is supportive care, and mechanical ventilation should only be used in these patients as a bridge to lung transplantation.
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Affiliation(s)
- Supparerk Disayabutr
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, Box 0111, San Francisco, CA, 94143-0111, USA.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, Box 0111, San Francisco, CA, 94143-0111, USA.
| | - Harold R Collard
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, Box 0111, San Francisco, CA, 94143-0111, USA.
| | - Paul J Wolters
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, Box 0111, San Francisco, CA, 94143-0111, USA.
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Ryerson CJ, Cottin V, Brown KK, Collard HR. Acute exacerbation of idiopathic pulmonary fibrosis: shifting the paradigm. Eur Respir J 2015; 46:512-20. [DOI: 10.1183/13993003.00419-2015] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The goal of this review is to summarise the clinical features, management, and prognosis of acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF). AE-IPF has previously been defined based on clinical and radiological features that include the subacute onset of dyspnoea, bilateral ground glass changes on chest high-resolution computed tomography, and the absence of an identifiable aetiology. The annual incidence of AE-IPF is typically reported at 5–15%, but is less common in mild disease. Features of diffuse alveolar damage are present when a biopsy is performed. Idiopathic pulmonary fibrosis (IPF) patients with acute respiratory worsening are often initially treated with high dose corticosteroids and antimicrobials; however, there are no clear data to support these therapies, and the short-term mortality of AE-IPF is ∼50%. Recent studies have shown that the features and prognosis of AE-IPF are similar to other causes of acute respiratory worsening, including infection, aspiration, air pollution and mechanical injury to the alveolar epithelium. Based on this emerging evidence, we propose a novel approach to the classification of acute respiratory worsening events in patients with IPF that focuses on clinical and radiological findings consistent with an underlying pathobiology of diffuse alveolar damage.
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Petrosyan F, Culver DA, Reddy AJ. Role of bronchoalveolar lavage in the diagnosis of acute exacerbations of idiopathic pulmonary fibrosis: a retrospective study. BMC Pulm Med 2015; 15:70. [PMID: 26160310 PMCID: PMC4702317 DOI: 10.1186/s12890-015-0066-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 06/30/2015] [Indexed: 12/17/2022] Open
Abstract
Background It has been recognized that despite previous stability some patients with idiopathic pulmonary fibrosis (IPF) experience acute clinical deteriorations called acute exacerbations of idiopathic pulmonary fibrosis (AEX-IPF). We hypothesized that pulmonary infection can be excluded based on clinical and laboratory data and that bronchoscopy with BAL is not mandatory in the diagnostic work-up of suspected AEX-IPF. Methods In this retrospective study we identified patients with acute respiratory failure who were evaluated for AEX-IPF at the Cleveland Clinic between January 2002 and December 2011. Univariate and multivariate analysis were performed with predefined risk factors and final diagnosis of AEX-IPF and pulmonary infection. All tests were performed at a significance level of 0.05. Results A total of 77 patients met the study inclusion criteria. Of these patients 47 (61 %) were diagnosed with AEX-IPF. Bronchoscopy was more likely to be performed in patients who were on cytotoxic medications (p < 0.05). In most cases the diagnosis of AEX-IPF versus pulmonary infection was based on combination of other microbiological, clinical, radiologic data and clinical judgment. A total of 10 patients out of 14 (71 %) with a final diagnosis of pulmonary infection were on steroids on admission versus 21 out of 63 patients (33 %) with other final diagnosis (p = 0.024, OR 7.817, 95 % CI 1.31–46.64). Conclusions Exclusion of infection in our IPF patient cohort was mostly based on factors other than diagnostic bronchoscopy with BAL. Based on our results we suggested an algorithm for management of IPF patients presenting with acute respiratory failure.
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Affiliation(s)
- Frunze Petrosyan
- Hospital Medicine Department, Johnston Health, University of North Carolina Health System, 509 N Brightleaf Blvd, Smithfield, NC, 27527, USA.
| | - Daniel A Culver
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Anita J Reddy
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Luppi F, Cerri S, Taddei S, Ferrara G, Cottin V. Acute exacerbation of idiopathic pulmonary fibrosis: a clinical review. Intern Emerg Med 2015; 10:401-11. [PMID: 25672832 PMCID: PMC7089322 DOI: 10.1007/s11739-015-1204-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 01/23/2015] [Indexed: 01/11/2023]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic and progressive fibrotic disease limited to the lung, with high variability in the course of disease from one patient to another. Patients with IPF may experience acute respiratory deteriorations; many of these acute declines are idiopathic and are termed acute exacerbations (AE) of IPF. In these cases, the exclusion of alternative causes of rapid deterioration, including heart failure, bilateral pneumonia or pulmonary embolism, is a challenging goal. AE may occur at any time during the course of IPF, although they are more common in patients with more progressive disease and gastroesophageal reflux. Surgical lung biopsy or even surgical procedures in organs other than the lungs may also trigger AE, mainly in rapidly progressive or advanced IPF. Current diagnostic criteria include the presence of new-onset ground glass opacities or airspace consolidation superimposed on an underlying usual interstitial pneumonia pattern seen on high-resolution computed tomography. The outcome is poor with a short-term mortality in excess of 50% despite therapy. Currently, there is no treatment with demonstrated efficacy for AE-IPF: empirical high-dose corticosteroid therapy is generally used, with or without immunosuppressive agents, with limited evidence. On the other hand, there is hope that new treatments to slow down progression of IPF will translate into a reduction of AE-IPF's occurrence. In conclusion, although significant progress in assessing disease severity in IPF has been made, AEs remain unpredictable and are associated with a high risk of death. Improvements in our understanding of the etiology, risk factors, clinical predictors and epidemiology are needed. It is the goal of clinical researchers in the field to provide respiratory physicians with evidence-based guidance to identify patients who may benefit from therapy for preventing or treating AE-IPF.
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Affiliation(s)
- Fabrizio Luppi
- Centre for Rare Lung Disease, University Hospital, Via del Pozzo, 71, 41124, Modena, Italy,
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Neurohr C, Behr J. Changes in the current classification of IIP: A critical review. Respirology 2015; 20:699-704. [PMID: 26011188 DOI: 10.1111/resp.12553] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 02/17/2015] [Accepted: 04/12/2015] [Indexed: 12/19/2022]
Abstract
Idiopathic interstitial pneumonias (IIP) are a heterogeneous group characterized by unknown aetiology. Establishment of a correct diagnosis of a distinct IIP requires a multidisciplinary approach integrating clinical presentation, physiological data, radiological appearance and histological findings. The 2013 update of the American Thoracic Society/European Respiratory Society classification summarises progress in the field of IIP and outlines potential areas for future research. The main entities defined by the 2002 statement on IIP are preserved, but major IIP are now distinguished from rare IIP and the new category of unclassifiable IIP is introduced. In addition, the existence of idiopathic non-specific interstitial pneumonia as a separate chronic fibrosing IIP and idiopathic pleuroparenchymal fibroelastosis as a specific rare entity are acknowledged. Moreover, the major IIP are categorized according to the features chronic fibrosing, smoking-related and acute/subacute clinical course. Furthermore, a clinical classification of IIP according to disease behaviour with suggestions for treatment goals and monitoring strategies is provided. The goal of this review is to discuss the areas of uncertainty in the updated multidisciplinary classification of IIP and point out potential consequences for clinical management.
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Affiliation(s)
- Claus Neurohr
- Department of Internal Medicine V, University of Munich, Munich, Germany
| | - Juergen Behr
- Department of Internal Medicine V, University of Munich, Munich, Germany
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31
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Jaguin M, Fardel O, Lecureur V. AhR-dependent secretion of PDGF-BB by human classically activated macrophages exposed to DEP extracts stimulates lung fibroblast proliferation. Toxicol Appl Pharmacol 2015; 285:170-8. [PMID: 25896968 DOI: 10.1016/j.taap.2015.04.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 04/03/2015] [Accepted: 04/07/2015] [Indexed: 11/29/2022]
Abstract
Lung diseases are aggravated by exposure to diesel exhaust particles (DEPs) found in air pollution. Macrophages are thought to play a crucial role in lung immune response to these pollutants, even if the mechanisms involved remain incompletely characterized. In the present study, we demonstrated that classically and alternative human macrophages (MΦ) exhibited increased secretion of PDGF-B in response to DEP extract (DEPe). This occurred via aryl hydrocarbon receptor (AhR)-activation because DEPe-induced PDGF-B overexpression was abrogated after AhR expression knock-down by RNA interference, in both M1 and M2 polarizing MΦ. In addition, TCDD and benzo(a)pyrene, two potent AhR ligands, also significantly increased mRNA expression of PDGF-B in M1 MΦ, whereas some weak ligands of AhR did not. We next evaluated the impact of conditioned media (CM) from MΦ culture exposed to DEPe or of recombinant PDGF-B onto lung fibroblast proliferation. The tyrosine kinase inhibitor, AG-1295, prevents phosphorylations of PDGF-Rβ, AKT and ERK1/2 and the proliferation of MRC-5 fibroblasts induced by recombinant PDGF-B and by CM from M1 polarizing MΦ, strongly suggesting that the PDGF-BB secreted by DEPe-exposed MΦ is sufficient to activate the PDGF-Rβ pathway of human lung fibroblasts. In conclusion, we demonstrated that human MΦ, whatever their polarization status, secrete PDGF-B in response to DEPe and that PDGF-B is a target gene of AhR. Therefore, induction of PDGF-B by DEP may participate in the deleterious effects towards human health triggered by such environmental urban contaminants.
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Affiliation(s)
- Marie Jaguin
- UMR INSERM U1085, Institut de Recherche sur la Santé, l'Environnement et le Travail (IRSET), Université de Rennes 1, 2 Avenue du Pr Léon Bernard, 35043 Rennes Cedex, France
| | - Olivier Fardel
- UMR INSERM U1085, Institut de Recherche sur la Santé, l'Environnement et le Travail (IRSET), Université de Rennes 1, 2 Avenue du Pr Léon Bernard, 35043 Rennes Cedex, France; Pôle Biologie, Centre Hospitalier Universitaire (CHU) Rennes, 2 rue Henri Le Guilloux, 35033 Rennes Cedex, France
| | - Valérie Lecureur
- UMR INSERM U1085, Institut de Recherche sur la Santé, l'Environnement et le Travail (IRSET), Université de Rennes 1, 2 Avenue du Pr Léon Bernard, 35043 Rennes Cedex, France.
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Esquinas AM, Iglesias AU, González AR. Staging and outcome in acute exacerbation of idiopathic pulmonary fibrosis: are all limits and determinants under control? Lung 2014; 193:155-6. [PMID: 25311431 DOI: 10.1007/s00408-014-9656-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 10/07/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Antonio M Esquinas
- Intensive Care Unit and Non Invasive Ventilatory Unit, Hospital Morales Meseguer, Avenida Marques Vélez s/n, 30008, Murcia, Spain,
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